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MedicalMedicalTemplatesTemplates

Making Medical Documentation

Simple and Painless

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ProblemProblem

A familiar lament . . .“No matter how much I write in my history and physical

exam note, I never seem to document enough tosubstantiate a high level encounter!”

Medical documentation is not about HOW MUCH you write!

It is about WHAT you write!

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MedicalTemplatesMedicalTemplatesCan Help!Can Help!

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What are MedicalTemplates?What are MedicalTemplates?

Standardized patient encounter forms using

Adobe PDF Technology

Use as a paper formOR

Complete form electronically

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MedicalTemplates FeaturesMedicalTemplates Features

Documentation promptersHCFA 1997 documentation guidelines

Quality remindersMedicare PQRI

Checkboxes Save time Save energy

Fillable Text Boxes

Easy to use Save time Save energy

Time saved is Money earned!

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The New Ambulatory EvaluationThe New Ambulatory Evaluation

Template from MedicalTemplatesTemplate from MedicalTemplates

Still has easy to use check boxes and fillable text boxes!

Now with new featuresROS with separate “yes” and “no” buttons for ease of 

documenting “pertinent positive and negative” findings “Reset” button for each section of ROS

Built in reminders of documentation guidelines for sections of thehistory and physical exam

Link button for 1997 Guidelines for Evaluation & ManagementServices

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Documentation reminders of requirements for the relevant section

Link to the 1997 Guidelines for Evaluation & Management Services

Separate “yes” and “no” options for documenting pertinent   positive and negative responses

Reset buttons

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Many Physicians Under Code!Many Physicians Under Code!

Most healthcare providers do more work than their documentation supports! 

And, as the saying goes,

if it isn’t documented, it didn’t happen!

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How Much Is At Stake?How Much Is At Stake?Fact

33-52% of patient encounters are UNDER coded  (JABFP 2001;14:184-92 and FPM October 2003 “How to get all the 99214s you deserve”)

Differences in Medicare reimbursement99214 -> 99215 = $30

99214 -> 99213 = $30 If you see 30 patients per day you may lose $300 or more per day!

[33%(30 patients/day) x $30/patient = $300/day]

Working 5 days/week for 50 weeks,

that is a potential loss of $75,000in just 1 year due to inadequate coding!!!

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What Is The Gain?What Is The Gain?

Decreasing billing and coding errors by just50% could mean an increase of nearly $40,000 per year in practice revenues! 

The equivalent of seeing an additional 690 patients/year 

Or, an extra 3 patients/day!WITHOUT THE EXTRA WORK!

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Benefits of MedicalTemplatesBenefits of MedicalTemplates

Easy to use Legible Fast and simple to complete Saves dictation and transcription costs Fast and simple to implement in any practice Standardizes documentation Enhances risk management strategies Reduces the risk of down codingWhen documentation is appropriate for billing code

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Professional, Medical and Legal BenefitsProfessional, Medical and Legal Benefits

Legible, thorough, and standardized documentationis a proven strategy to reduce riskThorough documentation becomes the standard of careImproved, thorough documentation can support

Audits of Billing codes – when correct code is billed for level of documentation

Mandatory Quality reporting Pay For Performance

Quality Assurance projects Maintenance of Certification projects – Self evaluation of practice performance

 – ABIM Practice Improvement Module

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A Quick Review of A Quick Review of 

Medical DocumentationMedical DocumentationRequirementsRequirements

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Patient EncountersPatient Encounters

  The Centers for Medicare and MedicaidServices (CMS) has published definitions anddocumentation guidelines for the key

components of a medical encounter note,using CPT codes.

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Key Components of DocumentationKey Components of Documentation

History

Exam

Medical Decision MakingCounseling

Coordination of Care

Nature of Presenting ProblemTime

1997 Guidelines for Evaluation & Management Serviceshttp://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf 

Key components inselecting the level of E/M services

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The HistoryThe History

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History Components and LevelsHistory Components and Levels

ComprehensiveCompleteCompleteExtended 

Detailed Pertinent Extended Extended 

Expanded 

Problem Focused 

N/AProblem

 pertinent 

Brief 

Problem Focused N/AN/ABrief 

Type of HistoryPFSHROSHPI

New patient evaluations MUST have at least a Detailed History 

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History of Present IllnessHistory of Present Illness

EVERY encounter MUST contain a Chief Complaint! Preferentially stated in patients’ words

Elements of HPI

Location

QualitySeverity

Duration

Timing

Context

Modifying factorsAssociated Signs and Symptoms

Brief 

Contains 1-3 elements listedExtended Contains ≥ 4 elements

OR discusses 3 chronic or inactive conditions

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Review of SystemsReview of SystemsConstitutional Symptoms

Eyes

Ears, Nose, Mouth, Throat

Cardiovascular 

Respiratory

GastrointestinalMusculoskeletal

Integumentary (Skin, Breast)

Neurological

Psychiatric

EndocrineHematologic/Lymphatic

Allergy/Immunologic

Problem Pertinent Documents responses to the systemdirectly related to the presentingproblem

Extended Documents positive and negativeresponses to 2-9 systems related tothe problem

Complete

Documents all positive and negativeresponses to systems related to thepresenting problem AND all other systems (10 or more total)

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Past, Family and Social HistoryPast, Family and Social History

Past Medical History Illnesses, Operations, Injuries and Treatments

Family Medical History Include heritable diseases and those that place the patient at increased risk

Social History An age appropriate review of past and current activities

Pertinent 

Document at least 1 item from ANY of the 3 areasIt must be directly related to the problems identified in the HPI

Complete 

 All initial inpatient services require a Complete PFSH 

Document at least 1 item from EACH of the 3 areas

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Recognized Single Organ SystemsRecognized Single Organ Systems

Cardiovascular Ears, Nose, Mouth, Throat

Eyes

Genitourinary (Female)

Genitourinary (Male)Hematologic/Lymphatic/Immunologic

Musculoskeletal

Neurologic

PsychiatricRespiratory

Skin

DetailedAn extended exam of the affected body areaor organs/organ system and another symptomatic or related area

Comprehensive

A general multi-system examA complete exam of an organ system and

other related body areas or organ systems

Most levels require a minimum of a Detailed Exam

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Multi-organ System ExamMulti-organ System Exam

Detailed ≥3 vital signs BP, sitting or standing BP, supine Pulse, rate and regularity Respirations Temperature

Height Weight

≥2 elements* of at least 6 organ systems or body areas examinedOR ≥1 element of at least 12 organ systems

Comprehensive≥2 elements* in at least 9 organ systems or body areas

*Refer to 1997 Guidelines for Evaluation & Management Services

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Single Organ System ExamSingle Organ System Exam

Detailed  Document ≥12 elements* (NOT Eye and Psychiatric exams)

Eye and Psych exams document ≥9 elements

Comprehensive

Document ALL elements*

*Refer to 1997 Guidelines for Evaluation & Management Services

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Elements of Individual Organ SystemsElements of Individual Organ SystemsConstitutional

Vital signs

General appearance of patient Nutrition, Body habitus, Development, Deformities,Grooming

Eyes Inspection of conjunctivae and lids Exam of pupils and irises Ophthalmoscopic exam of optic discs

Ears, Nose, Mouth and Throat

External inspection of ears and nose Otoscopic exam Assessment of hearing Inspection of nasal mucosa, septum,

and turbinates Inspection of lips, teeth and gums Exam of oropharynx

Neck

Exam of neck Thyroid

Respiratory Assessment of effort Percussion of chest Auscultation Palpation of chest

Cardiovascular  Palpation of heart

Auscultation Carotid artery exam Abdominal aorta exam Femoral arteries exam Pedal pulses exam Extremities for edema or varicosities 

Chest (Breasts) Inspection

PalpationGastrointestinal

Abdominal exam Liver and spleen exam Hernia presence or absence Anus, perineum, rectum exam Stool for occult blood

1997 Guidelines for Evaluation & Management Services

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Exam elements, continuedExam elements, continuedLymphatic

Neck Axilla Groin Other 

Musculoskeletal Gait and station Inspection, palpation digits and nails

Exam of bones, joints, muscles AND1 or more Inspection or palpation Range of motion and

presence/absence of pain Stability Muscle strength and tone

Skin Inspection

PalpationNeurologic

Cranial nerves Deep tendon reflexes Sensation

Psychiatric

Judgment and insight Orientation to person, time, place Memory, recent and remote Mood and affect

Genitourinary

Male

Scrotal contents Penis Digital rectal exam of prostate gland

Female External genitalia Urethra Bladder exam

Cervix Uterus Adnexa/parametria

1997 Guidelines for Evaluation & Management Services

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Medical Decision MakingMedical Decision Making

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Complexity of Medical Decision MakingComplexity of Medical Decision Making

HighHighHighExtensiveExtensive

ModerateModerateModerateModerateMultiple

LowLowLowLimitedLimited

StraightforwardStraightforwardMinimalMinimal or NoneMinimal

Complexity of Decision

Making

Risk of 

Complications

and/or Morbidity

or Mortality

Amount and/or 

Complexity of Data to

be Reviewed

Number of 

Diagnoses

Or Management

Options

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Examples of Examples of 

DocumentationDocumentationRequirementsRequirements

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Initial Hospital CareInitial Hospital CareMust meet all criteria 

99223 Comprehensive History and Exam

High complexity Medical decision making

99222 Comprehensive History and Exam

Moderate complexity Medical decision making

99221

Detailed OR Comprehensive History and Exam Straightforward or Low Complexity Medical decision making

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Initial Inpatient ConsultationInitial Inpatient ConsultationMust meet all criteria

99255 Comprehensive History AND Exam High complexity medical decision making

99254 Comprehensive History AND Exam Moderate complexity medical decision making

99253

Detailed History AND Exam Low complexity medical decision making

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New Outpatient Encounter New Outpatient Encounter Not a ConsultNot a Consult

Must meet all criteria

99205Comprehensive History and Exam

High complexity medical decision making

99204Comprehensive History and Exam

Moderate complexity medical decision making

99203Detailed History and Exam

Low complexity medical decision making

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New Outpatient ConsultNew Outpatient Consult

Must meet all criteria99245

Comprehensive History Comprehensive Exam High complexity medical decision making

99244 Comprehensive History Comprehensive Exam Moderate complexity medical decision making

99243 Detailed History Detailed Exam Low complexity medical decision making

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Established Outpatient Encounter Established Outpatient Encounter 

Must meet 2 out of 3 criteria99215

Comprehensive History Comprehensive Exam High complexity medical decision making

99214 Detailed History Detailed Exam Moderate complexity medical decision making

99213 Expanded Problem Focused History Expanded Problem Focused Exam Low complexity medical decision making

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We hope you found this presentationhelpful!

We are grateful to all the patient andknowledgeable billing and coding specialists wehave encountered along the way!

We welcome your comments atwww.e-medtools.com